Provider Demographics
NPI:1174838411
Name:PHILIP R. WISIACKAS, M.D., P.A.
Entity Type:Organization
Organization Name:PHILIP R. WISIACKAS, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WISIACKAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-653-4223
Mailing Address - Street 1:110 HILL AVE
Mailing Address - Street 2:
Mailing Address - City:COLDSPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77331-5406
Mailing Address - Country:US
Mailing Address - Phone:936-653-4223
Mailing Address - Fax:936-653-5042
Practice Address - Street 1:110 HILL AVE
Practice Address - Street 2:
Practice Address - City:COLDSPRING
Practice Address - State:TX
Practice Address - Zip Code:77331-5406
Practice Address - Country:US
Practice Address - Phone:936-653-4223
Practice Address - Fax:936-653-5042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-11
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00FS32OtherBLUE CROSS/BLUE SHIELD
TXE28279Medicare UPIN